Even though many practices employ nurse practitioners, physician assistants, and other nonphysician practitioners (NPP) to make the office more efficient, some simply do not use them optimally or have the right personnel performing the right tasks. Moreover, practices may not be aware of coding regulations when services are rendered by NPPs, which may result in improper coding and inadequate reimbursement.
Perhaps most important from a business standpoint is to make sure that the NPPs are following regulations to ensure proper coding of the services they provide, and, in turn, ensure that the practice receives proper reimbursement.
"The biggest problem is that they are underutilized, then when they are utilized, they are not utilized properly," says Maggie M. Mac, CMM, CPC, CPC-E/M, ICCE, consulting manager at accounting firm Pershing Yoakley & Associates. "I think the biggest problematic area is misunderstanding or misuse of incident-to, and they get into trouble for this because there is a lot of focus on this from the [Office of Inspector General (OIG)]."
Incident-to services are those that are performed by an NPP and can be billed to Medicare. To qualify as incident-to services, Medicare requires certain regulations to be followed, including that an NPP can see a patient that has previously been seen by a physician, as long as the physician has written down a plan of treatment.
When the NPP sees the patient for follow-up, he or she must follow the physician's treatment plan to the letter, Mac says. If the physician makes any changes, or there are new problems or symptoms to be reviewed, the practice has to bill it differently and may not be able to maximize profitability, she says.
"Under the physician's name, [Medicare] pays it at 100%," Mac says. "Even though [the NPPs have] performed the work, they've actually carried out a plan of treatment without any changes or seeing the patient for any new problems. They can bill it under the physician's name, get 80% of 100% reimbursement versus if they billed it under their own ID and number, they would get 80% of 85% of the allowance."
Under incident-to rules, a physician has to be in the building when the service is rendered, but it does not have to be the same physician that outlined the treatment plan either, simply a physician from the practice, Mac notes.
However, NPPs and physicians need to be aware of the coding and billing rules. Without that communication, there could be OIG sanctions due to coding violations.
This article was adapted from one that originally ran in the January 2009 issue of The Doctor's Office, a HealthLeaders Media Publication.
The beginning of a new year often prompts reflection, resolutions, and for columnists, a few words about what to expect in the coming months. The problem in 2009, though, is that I don't have a clue what to expect.
That isn't meant as a copout. I called Jeff Bauer, PhD, a healthcare futurist who makes a living analyzing and predicting the future of the healthcare market, and he says essentially the same thing.
"Expect not knowing what to expect," he says. "Anyone who goes into 2009 believing some prognosticator is likely going to be disillusioned and misled. The number one point I'm telling people is to be prepared for uncertainty and surprises. Be flexible."
The coming year will in many ways be a continuation of the previous—we're waiting to see the full effects of a power-shifting election and the worst financial crisis in decades. How it plays out is anyone's guess.
That said, I'll offer a few:
1. Healthcare reform will be a priority. Not long ago, that would have been obvious. But many people, including Bauer, now think the economic crisis is too severe for the Obama administration to focus on reforming healthcare. And they may be right—it depends on how much worse the economy gets and how long the recession and credit crunch last. But the impetus will likely come from Congress—both Ted Kennedy and Max Baucus have already started preliminary work—and the Obama administration may see healthcare reform as a way to stimulate the economy and boost Americans' confidence. I predict they'll take a shot at it before the end of the year. I'll add this caveat: The healthcare reform package that makes it through will be only incrementally helpful. Physicians and other providers will still be facing many of the same problems after it passes.
2. Provider relationships will be redefined. Recent changes to the marketplace and new cost and performance pressures are redefining relationships, and physicians should be prepared to reevaluate their partnerships with other physicians, hospitals, and health plans, Bauer says. Employment arrangements will continue to be popular, and as a result, there will be a greater need for physicians in leadership positions to avoid the mismanagement that accompanied the employment wave of the mid-90s.
"We need to be looking for more physicians in management, including being CEO and COO," Bauer says.
When it comes to health plans, physicians are going to have to take a look at renegotiating some of the perverse incentives in the current reimbursement system.
3. Consolidation will accelerate. I wrote in our October magazine cover story about small mom-and-pop physician practices consolidating and selling—because of cost pressures, economy of scale advantages, and necessary technology upgrades. The bad economy will only accelerate this consolidation trend, for both physician practices and hospitals.
The most successful physician groups will be those that grow through mergers or acquisitions of other practices, and more physician owners will consider selling their practices to a hospital or health system. Capital may be hard to come by, but it will be a buyer's market.
4. EMR adoption rates will jump. This prediction may be mostly wishful thinking, but EMR adoption rates can't continue at such a slow pace for much longer. Whether it's part of a comprehensive healthcare reform package or another piece of legislation, I think we'll see some incentives from the federal government to help physicians upgrade. Even without that, the consolidation trend and growing quality pressures will push more doctors into practices with EMRs.
Does that mean a lot more physicians will be working with EMRs this time next year? Not necessarily. But the adoption rate will speed up and changes will be in place to make it easier for the following years.
But like I said, so much hinges on the new administration's goals—and how much the economy lets them focus on healthcare—that it's difficult to make predictions with a high degree of certainty. Your guess is as good as mine.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
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Two Phoenix-area hospital systems have ended their training programs for family-practice physicians, citing economic concerns and also fewer young doctors choosing family medicine. While family doctors can help patients manage their health and stave off troublesome and costly medical conditions, the prospect of a career in this area is becoming a less appealing option for medical students because it typically pays far less than what a surgeon or dermatologist can pocket.
Despite ever-emerging technologies, many physicians remain hesitant to adopt an electronic medical records system. Experts cite economics as a reason, as many say they are simply not seeing enough financial benefits.
Physician groups in Modesto, CA, and Boulder County, CO, will each settle separate Federal Trade Commission claims. Both groups are charged with orchestrating and carrying out agreements among their members to refuse, and threaten to refuse, to deal with insurance providers, unless they raised the fees paid to the groups' doctors. The settlement prohibits each group from engaging in similar conduct in the future, to ensure protection of the competition.
Based on the considerable reader feedback I received in response to my column on the practice of shifting emergency department patients to inpatient hallways, the quality and patient safety community has some fervent—and often disparate—opinions about how hospitals should deal with ED overcrowding. Many of you offered some candid remarks about your experiences at your organizations, so I thought I would share some of the comments to give the rest of you a chance to see what your fellow readers think about this often contentious issue and the viability of a "third option" beyond ED boarding or hallway medicine. Some of the e-mails have been edited for length.
We can't choose ED boarding or hallway inpatients
Let me speak as a former ED nurse: I have worked in a large metro hospital ED, and we ran out of "room in the inn" often. We would have patients in the hallways on gurneys waiting to be seen by the ED doc. Med sheets would not print for patients; they all had to be hand-written. ED documentation records did not support the type of assessments and checks that are done by med/surg or ICU nurses. Calling the attending physicians for orders and then getting them transcribed or entered was often a challenge, as procedures and routines are different. Lots of opportunities for errors.
Now, let's couple that with some other issues. Most ED nurses are ED nurses for a reason: They don't like "bedside care." Patients do not get turned, bathed, mouth care for vents, or other kinds of "maintenance issues." Also, there is usually no "extra help" afforded with the increase in census—so the emergent patients are first priority. There is a mental "move on to the next patient" when the admission orders are written.
Housing patients in the hall on the floor has many of the same issues. Where is the bathroom? Where is any privacy? What does the family do—stand alongside your bed in the hall as well? How can medications/tests/labs be SAFELY administered without real estate with a room number attached? What of fire codes? What about surveyors? (I would be very interested to hear if any facility that does this has been under survey at the time.)
Nope. Neither of these is safe, in my estimation. I will choose Option No. 3 as well, for me and mine.
Charlene Boggs, RN,Director of Quality Resources, JohnsonMemorial Hospital, Franklin, IN
Look beyond symptoms to the cause
All I'm reading and hearing is that patients are stacked up in the ED waiting for an inpatient bed, but I'm not reading or hearing the reasons why the patient can't get admitted to the inpatient floor. If it is the lack of staff or inpatient beds, then you're never going to solve that issue. Whether the patient is kept in the ED or in the inpatient hallway, the real solution is to get them admitted. So, what are the issues hospitals are struggling with on the inpatient setting that is preventing this from happening? That is where the focus should be.
Hospital quality services director,Name withheld by request
Idea is to pull patients up, not push them out
This is an issue we have been grappling with at my hospital for the past several years. The problem I have with your Option No. 3 and improving ED efficiency is that it only improves throughput on the front end and decreases waiting times to care. It doesn't decrease the number of patients awaiting admission and, depending on how well that process works during peak volume times, may actually increase the number of hallway patients in the ED during certain times of the day.
In answer to your question about whether patients in the ED hallway are any less safe than in a hallway two floors up, I would answer, "Absolutely!" The ED specializes in acute care, and their priority will always be the new patients, especially those with life-threatening presentations. By definition, the admitted patient is the sickest category of patients in the ED, but the staff taking care of them are now focused elsewhere. I believe that spreading the care of these patients with the areas that specialize in that care is the safest route.
The concept of hospital floor hallway patients, though not ideal, is that patients are "pulled" up to the floors (rather than being "pushed" from the ED). The floors are then stimulated to discharge patients earlier than routine to make space for the newly arrived, highly visible, hallway patients. It also decreases the ED crowding burden and allows the ED to concentrate on acute care. I think Option No. 3 regarding hallway patients lies not in improving ED efficiency, but with improving the discharge process, length of stay, and numbers of hospital beds within each hospital.
Stephen T. Holland, MD,Chief Medical Officer, Saint Mary's Health System, Waterbury, CT
Deal with elective surgery schedule
As a former VP for perioperative and emergency services at a large Midwest level 1 trauma center, I must admit I was tempted to advocate [placing patients in hallways] in my organization. However, I know now, as I did then, that the ED is at the mercy of the inpatient capacity of the hospital, and the inpatient capacity of the hospital is driven by the elective surgery schedule. The peaks and valleys we see in most hospitals can be traced directly to the variability of the elective schedule in the OR—those that are scheduled in advance, not the emergencies from the ED. Most ED directors can tell you very easily how many patients they will admit from the ED next Thursday, but very few OR directors can tell you how many patients will be electively admitted from the OR. The end result is large peaks and valleys that cause patients to be placed in inappropriate inpatient beds with nurses who may be unprepared, overworked, or simply not accustomed to caring for that type of patient. That leads to delays, cancellations, increased risk of morbidity and mortality—and ultimately huge increases in cost that we all have to bear. The answer to this is not placing patients in hallways anywhere but to fix the root of the problem, which is the elective surgery schedule. Hospitals are reluctant to do this because they are afraid their surgeons will leave and take their business with them. However, hospitals we've worked with and the surgeons who work in those hospitals have actually benefitted by addressing the root of the problem. We have seen hospitals increase their capacity both in the OR and the hospital without building costly infrastructure or hiring more people (or putting anybody in the hall).
Christy Dempsey, RN,Senior Vice President for Clinical Operations, PatientFlow Technology, Inc., Boston
Obvious solutions not always right solutions
Hospitals are taking a wide variety of steps to solve their ER overcrowding issue. No one solution works for all hospitals. We have tried to optimize our ER throughput in a variety of ways in the ER, and are now bottlenecked because we don't have enough beds at any given time. We are taking a very comprehensive approach, starting out by looking at "wasted beds," and trying to match demand to capacity. We got started by sending several teams to the IHI's course on hospital throughput, and now have an operations group working on this problem. The obvious solutions are not always the right solutions, as we are finding that throughput is affected by multiple factors, all of which must be understood and optimized before the right solutions can be implemented.
David McGreaham, MD,Vice President of Medical Affairs, Munson Medical Center, Traverse City, MI
As you can see, the problem of ED overcrowding may be a universal one, but opinions about what to do about it are all over the map. I still don't know what the answer is—in fact, I don't think there is a singular right answer—but I'll continue to keep watch for inventive solutions.
Jay Moore is managing editor for HealthLeaders magazine. He can be reached at jmoore@healthleadersmedia.com.
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